Updated: 2/13/2018

Testicular Tumors

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https://upload.medbullets.com/topic/116050/images/seminoma_of_the_testis.jpg
Introduction
  • Testicular tumors can be of germ cell or non-germ cell origin
    • germ cell origin
      • are the majority (95%) and are more commonly malignant
    • non-germ cell origin
      • usually benign
  • Epidemiology
    • incidence
      • most common cancer in men between 15-35 years
    • risk factors
      • cryptorchidism
      • Klinefelter syndrome
      • testicular feminization
Classification
  • Germ cell types
    • seminoma
      • malignant
      • most common testicular tumor
      • mostly affecting males 15-35 years
      • commonly metastasizes to para-aortic lymph nodes before hematogenous spread
    • embryonal carcinoma
      • malignant
      • commonly metastasizes hematogenously first
    • yolk sac (endodermal sinus) tumor
      • seen in children < 4 years
    • choriocarcinoma
      • malignant
    • teratoma
      • mature teratoma in males is most often malignant
        • unlike females
  • Non-germ cell types
    • Leydig cell (sex-cord stromal)
    • Sertoli cell (sex-cord stromal)
    • Testicular lymphoma
      • most common testicular cancer in older men
      • involves both testes
Presentation
  • Symptoms
    • painless unilateral enlargement of testes
    • seminoma
      • homogenous testicular enlargement
    • embryonal carcinoma
      • painful
    • choriocarcinoma
      • gynecomastia
        • due to hCG production which is an LH analogue
    • Leydig cell
      • usually androgen producing
        • gynecomastia in men
        • precocious puberty in boys
  • Physical exam
    • solid mass of the testes is always cancer
Evaluation
  • Histology
    • seminoma
      • large cells in lobules with watery cytoplasm  
      • "fried egg" 
        • analogous to dysgerminoma of the ovary
    • embryonal carcinoma
      • glandular/papillary
    • yolk sac (endodermal sinus) tumor
      • yellow, mucinous
      • Schiller-Duval bodies resemble primitive glomeruli
    • choriocarcinoma
      • disordered syncytiotrophoblastic and cytotrophoblastic elements
    • teratoma
      • contain three tissue types
    • leydig cell
      • contains Reinke crystals
      • golden brown color
  • Serology
    • LDH
      • non-specific
    • specific tumor markers
      • embryonal carcinoma
        • ↑ AFP and hCG
      • yolk sac (endodermal sinus) tumor
        • ↑ AFP
      • choriocarcinoma
        • ↑ hCG
Treatment
  • Pharmacologic & radiation
    • radiation therapy
      • indications
        • seminoma is radiosensitive
  • Surgical
    • orchiectomy 
Prognosis
  • Seminoma
    • late metastasis and excellent prognosis
  • Embryonal
    • worse prognosis than seminoma
  • Choriocarcinoma
    • worst prognosis
      • in contrast to good prognosis in females
      • metastasizes to lungs
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.ON.57) A 45-year-old man presents to his primary care provider for his yearly physical. On exam, the physician discovers a hard, testicular mass on the right testis. On further questioning, the patient remarks that he first noticed it 6 months ago, but did not think he needed to have it examined since it wasn't painful. Transillumination of the scrotum does not reveal translucency. The ultrasound of his right testis is shown in Figure A. Blood work reveals normal AFP and Beta-hCG. Chest radiograph and CT scan do not show positive lymph nodes or distant metastases. Which of the following is the most appropriate next step? Review Topic

QID: 106375
FIGURES:
1

Biopsy

60%

(6/10)

2

Radical orchiectomy

30%

(3/10)

3

Chemotherapy

0%

(0/10)

4

Three month re-imaging

10%

(1/10)

5

No further workup, instruct patient to return if symptomatic

0%

(0/10)

M1

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